There is little doubt that the physical wellbeing of individuals in the workplace is the primary focus of most organisational Occupational Health and Safety programs. Scan the OH&S section of an employee manual or company intranet and you will see reference to hazardous materials, equipment handling, repetitive strain injury, noise, heat stress, fatigue and falls. Peruse the literature published by any of the State-based WorkCover bodies and you will find a firm commitment to reducing fatalities and employee incapacitation through serious physical injury.

This preoccupation with the physical welfare of Australian workers is warranted. To lose a loved one to their work is tragic and workers' compensation claims for physical injury do account for 93 per cent of total claims made. But what of psychological wellbeing at work? What are the effects that work is having on the emotional state of individuals? Who is vulnerable and what can be done to reduce the risk of psychological injury? Finally, as psychologists, how can we aid in the maintenance of psychological wellbeing at both the organisational and individual levels?

The Centre for Corporate Health (CFCH) is heavily involved in the assessment of psychological injury claims (commonly known as 'stress' claims) which account for the remaining seven per cent of WorkCover claims. Employed as independent specialists by workers' compensation insurance bodies in New South Wales and the Australian Capital Territory, CFCH's psychologists travel throughout NSW, ACT and northern Victoria to undertake clinical interviews with individuals who have lodged claims for psychological injury. These psychologists gather stories of workplace difficulties from often emotionally fragile people and ascertain their symptoms of distress.

The focus then shifts from the individual to the employer. The psychologist attends the workplace and interviews managers, supervisors and colleagues to gain a fuller understanding of the situation that has led the individual to lodge a claim. The views of treating practitioners such as general gractitioners, clinical psychologists and psychiatrists are sought and the full account is written up with recommendations as to the degree of psychological injury (if any,) its work-relatedness and possibilities for treatment and return to work. This is known as a Pre-Liability Assessment and is reported to the insuring body. It is on the basis of this report that a determination of the liability of claims is made.

Data from the front line

In this article we highlight themes emerging from a review of approximately 400 of these Pre-Liability Assessments undertaken by the Centre For Corporate Health in 2004. Our aim in undertaking this review has been to establish whether work is the primary cause of the distress or psychological injury cited, or whether there are other factors at play. If work is the cause, what is occurring in the workplace that makes individuals vulnerable to such distress? And if work is not the cause, what is it that is leading these individuals to lodge a claim for psychological injury?

The work-relatedness of psychological injury claims

In approximately 70 per cent of the 400 claims reviewed the distress cited by the individual was deemed to be legitimately caused by work-related factors. It appears that work is having an impact on the wellbeing of many individuals.

For those organisations specialising in the provision of human services, in which exposure to traumatic incidents or threatening acts involving clients was more likely, 90 per cent of claims were deemed to be substantially work related. Such claims were related not only to the exposure of critical incidents but were also related to the subsequent management of support issues following the incident. Other work factors leading to claims for psychological injury included being the subject of performance investigations or complaints, performance management, exposure to aggressive clients, conflict with colleagues, high workload, poor management skills of supervisors, transfers, and poor person-job fit.

For those organisations in which exposure to critical incidents was less likely, the likelihood that work was the cause of the injury was lower. The issues raised were deemed to be substantially and legitimately work-related in only 60 per cent of these cases. In the remaining 40 per cent, non-work factors were deemed to have led to the individual's distress. The most prominent of these non-work factors were pre-existing personality styles that led a person to be particularly vulnerable to ordinary workplace stressors. Also prominent were high levels of vocational discontent expressed by the individual prior to the individual submitting a claim for psychological injury. Other non-work related factors included personal issues such as health, family or financial issues and pre-existing psychological issues such as psychological disorders that had not fully remitted at the time of the claim.

The degree of distress

The overwhelming trend in all claims submitted for psychological injury and assessed in this review was the existence of clinical levels of distress. In approximately 85 per cent of all claims reviewed, evidence was found to suggest that, whether the issues were deemed work-related or not, the claimants were suffering from clinical levels of distress and could be assigned a diagnosis as defined by the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition. It appears that those lodging WorkCover claims for psychological injury are doing so only once their distress has become significant.

In the majority of cases the individual's symptoms of distress met the criteria for an Adjustment Disorder and to a lesser extent, Major Depressive Episode and Post Traumatic Stress Disorder. The fact that most claimants were assessed as meeting the criteria for an Adjustment Disorder is a favourable prognostic sign for rehabilitation, given that the symptoms are treatable and tend to resolve within a relatively brief period with the appropriate psychotherapeutic and medical assistance.

Who is vulnerable and what can be done?

It appears that those most vulnerable to psychological injury are individuals working in organisations in which they are more likely to be exposed to critical incidents. Access to psychological counselling through Employee Assistance Programs (EAPs) is often available to these individuals, and this assists with the management of distress and the expedience of an effective return to work and to full emotional health.

Work-related factors such as performance investigations or complaints, performance management, exposure to aggressive clients, conflict with colleagues, high workload, the poor management skills of supervisors, transfers and poor person-job fit are also relevant, however. Several of these (performance management, performance investigations, transfers, promotions, demotions, employment contract terminations and grievance management) are discounted by the NSW Workers' Compensation Act as legitimate causes of psychological injury for which an employer could be held liable, as long as the employer has handled these matters in an appropriate manner.

In our assessment it appears that the likelihood of such appropriate handling varies depending on the size, structure and availability within the organisation of internal human resources to assist line managers in handling these matters. For those organisations in this review with a highly centralised organisational structure and well developed policies and procedures, managers were deemed to have handled human resource issues effectively in approximately 95 per cent of claims. However, in smaller organisations in which policies and procedures tended to remain undeveloped and managers were largely untrained in human resources issues, these issues were deemed to have been managed effectively in only about 40 per cent of the claims reviewed.

Strategies for reducing the risk of psychological injury

In terms of mitigating the risk of psychological injury caused by these and other work and non-work factors, there are a range of individual and organisational-level strategies that can be implemented. At the individual level, strategies include management training in skills such as providing performance feedback and managing underperformance, coaching and mentoring staff, managing the impact of organisational change on others, managing critical incidents, and conflict management and grievance handling. Career coaching to manage issues such as vocational discontent and the early warning signs of distress associated with this can also be helpful, as can occupational stress resilience programs aimed at enhancing emotional resilience in the workplace and the prevention of burnout.

Improving the quality of workplace relationships is also important in mitigating the risk of psychological injury and in helping individuals to recover from emotional distress and return to work. Relevant interventions for improving workplace relationships include training employees in improving individual communication, understanding and resolving differences, assertiveness and teamwork.

At the organisational level, strategies such as well-developed recruitment and selection processes incorporating psychometric assessment can ensure better job-person fit. This can be particularly effective in reducing the risk of psychological injury resulting from non-work factors such as personality styles that increase the likelihood of individuals becoming vulnerable to distress under certain circumstances.

Our data review suggests that the personality styles more often associated with a claim for psychological injury include a highly personalised and sensitive reaction to ordinary workplace events (high levels of emotionality), perfectionist traits, a paranoid and distrustful thinking style, a somewhat rigid and inflexible thinking style, and high levels of self focus (that is, a strong sense of entitlement and tendency to view oneself in a highly positive manner despite contradictory information from supervisors.) Such personality styles are not in and of themselves problematic at work, but a poor match between the individual's personality style and the requirements of their role or the culture of the organisation can lead to dysfunction, distress and a psychological injury claim.

Other organisational-level interventions include climate and culture surveys, which can be used to assess the state of workplace relationships, perceptions of supervisory skills, organisational morale and vocational discontent. The development of robust, meaningful and effective policies and procedures pertaining to the employment and management of people, and training in these for anyone in a supervisory or management position, can also be effective and worth the required expenditure. Finally, the prevalence of access to Employee Assistance Programs amongst the organisations whose psychological injury claims were reviewed may explain the lesser incidence of claims resulting from personal factors such as health, family or financial issues, and suggests that these programs continue to be effective in maintaining wellbeing in the workplace.

A final, interesting theme to emerge from our case review which may indicate a vulnerability factor in relation to WorkCover claims for psychological injury was the average age of claimants.Amongst the cases reviewed the average age of claimants was 41-45 years, followed by 50 years and older. This suggests that the effective management of individuals in the second half of their careers may be imperative in the quest to minimise psychological injury.

Our review suggests that individuals aged over 40 are at greater risk of experiencing distress as a result of burnout and vocational discontent, much of which appears associated with organisational change. Interventions that may reduce the likelihood of such distress include training to develop enhanced awareness of generational and individual differences, particularly for younger managers required to supervise those who have been in their roles for some time, as well as training to develop improved understanding of the implications and effective management of workplace change. Monitoring of the impact of these changes and ongoing job satisfaction amongst those aged over 40 also appears important.

As psychologists we have an important role to play in not only the assessment and treatment of psychological injury and work-related distress but also in the education of individuals, organisations and the community about the aspects of work that are having an impact on psychological wellbeing, and the implementation of proactive strategies to reduce the risk of psychological injury and maintain emotional wellbeing. Given that the average cost of a psychological injury claim has escalated in recent years to $27,798 per claim compared with $18,913 for a physical injury claim and the average time off work has increased to a high of 21 weeks compared with 8 weeks for a physical injury claim (WorkCover NSW Statistical Bulletin 2003/04), public and private sector bodies have an even greater incentive to engage our assistance and to ensure that the profile of psychological wellbeing in the workplace is raised and takes its place in the Occupational Health and Safety strategies of organisations, Australia-wide.